Extended Duration Ticagrelor Therapy Following Myocardial Infarction - Leeds Teaching Hospitals Guidance on

Publication: 03/04/2017  --
Last review: 01/01/1900  
Next review: 03/04/2020  
Clinical Guideline
ID: 4980 
Approved By: Trust Drug and Therapeutics Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  


This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Leeds Teaching Hospitals Guidance on Extended Duration Ticagrelor Therapy Following Myocardial Infarction


  1. Ticagrelor 60mg twice daily should be prescribed, in addition to aspirin 75mg daily, for selected patients with history of myocardial infarction within two years who are at high risk of further events.
  2. Extended duration ticagrelor therapy 60mg twice daily should be continued for three years. In most cases this will comprise down-titration from 90mg twice daily prescribed for twelve months following myocardial infarction.
  3. Because protection from further cardiovascular events is offset by an increased risk of major bleeding, the decision to prescribe extended duration therapy should be made by a clinician familiar with assessing risk following acute coronary syndrome (usually a consultant cardiologist).
  4. In most cases, patients who will benefit from extended duration therapy will be identified during their admission with index myocardial infarction, taking into account findings at angiography (where available), risk factors and consideration of bleeding risk.
  5. Bleeding risk should be calculated using the PRECISE-DAPT score. Patients with PRECISE-DAPT≥25 should not routinely be offered extended duration ticagrelor.
  6. One or more of the following risk factors should be taken into consideration when assessing the risk of future events:
    1. Age over 65 years
    2. Diabetes mellitus requiring medication
    3. Previous myocardial infarction in addition to index event
    4. Multivessel coronary artery disease
    5. Chronic kidney disease (eGFR < 60ml/min) not requiring dialysis
  7. The recommendation for extended duration therapy must be clearly documented in the case notes and communicated to the general practitioner on the eDAN as follows:

    Please continue ticagrelor 90 mg twice daily for 1 year and then downtitrate to 60 mg twice daily for a further 3 years, if tolerated, in view of extent of coronary artery disease and clinical risk factors. Continue aspirin, statin and other secondary prevention medication long term.

  8. A service for remote review of ticagrelor continuation at 12 months following MI is available to primary care.  Recent full blood count, renal function and history of bleeding are required for referral to the service – email leedsth-tr.ticagrelorreviewservice@nhs.net


Ticagrelor is contraindicated in patients with active pathological bleeding, a history of intracranial haemorrhage, or moderate-to-severe hepatic impairment. Co-administration of ticagrelor with a strong CYP3A4 inhibitor (for example, ketoconazole, clarithromycin, nefazodone, ritonavir or atazanavir) is also contraindicated.


Record: 4980
Clinical condition:
Target patient group:
Target professional group(s): Pharmacists
Secondary Care Doctors
Adapted from:

Evidence base

  1. Bonaca MP et al; for the PEGASUS-TIMI 54 Steering Committee and Investigators. Long-Term Use of Ticagrelor in Patients with Prior Myocardial Infarction N Engl J Med 2015;372:1791-800.
  2. NICE Technology Appraisal 420. Ticagrelor for preventing atherothrombotic events after myocardial infarction. Published 14 December 2016
  3. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. doi:10.1093/eurheartj/ehx419

Approved By

Trust Drug and Therapeutics Group

Document history

LHP version 1.0

Related information

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